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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL RECORD 5 5 9 6 4 4 <br /> Minnesota Stafutes Chapter f031 <br /> �zt'. <br /> _ Township Name� + Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> n. <br /> ;� <br /> ,-- �.�: �ra �� ��a�,. ��,� s�,��,. <br /> ., <br /> Numerical Street Address and City of Well Location e or Fire Number DRILLING METHOD <br /> ❑ Cable Tool ❑ Driven ❑ Dug <br /> � ;��� - - B.].�t%� ❑ Auger ❑ Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ <br /> i Showing property lines, <br /> N �,'�;'^ = ,.,�, � .. `�-�',�'; roads and buildings. DRILLING FLUID <br /> I i � � A - <br /> --r--7- -' -1- . .. _. ...') ;`t.-= +"...; ..y <br /> i � � ,USE ❑ Heating/Cooling <br /> _�_ _�_ �_ �_ CL Domestic ❑ Monitoring ❑ Industry/Commercial <br /> yy i � I E ❑ Irrigation ❑ Public <br /> _1_ _1_ __ __ T ❑ Test Well ❑ Dewatering O Remedial <br /> I ' � ' <br /> ' r-mi. CASING Drive Shce? ❑ Yes p No HOLE DIAM. <br /> � 1 <br /> --�- �- ; -r- I ❑ Steel ❑ Threaded C Welded <br /> -� ' ' 1 <br /> [,x.Plastic ❑ <br /> �—1 milr� <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME in.ro _i'�.t.� � IbsJft. �Z in.to-'� ft. <br /> i'�. -:�_;. in.to fl. IbsJfl. �in.to.��;_�ft. <br /> .._' � <br /> Mailing address if different than property address indicated above. in.to fl. . Ibs.ttt. in.to R. <br /> SCREEN OPEN HOLE <br /> Make . '.�1 i ��1�-� from ft.ro ft. <br /> Type . - Diam. ' <br /> ,.. <br /> SbVGauze � � y��r� Length 'i�l � <br /> Set between i�'� tt.and ?r.,� ft. FITTINGS: <br /> STATIC WATER LEVEL <br /> HARDNESS OF <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO ;;Q':' ;r=; ft.��] below ❑ above land surtace Date measured 7 �� <br /> PUMPING LEVEL(below land surface) <br /> :�:3..::i F �c .` ?•t���;: ��Z rJ:;�C! ..... .:_�i: � : c.� tt. after hrs.pumping `�t� g.p.m. <br /> WELL HEAD COMPLETION <br /> `..:i_, � ..:�t;).'�;,1 I1 .:,;�3 i ��.. ;.�� „��, ❑':Pitless adapter manufacturer ".i�-�`',��,c� �<;;t�.:'Y Model ', � ��-�L � <br /> G Casing Protection ❑ 12 in.above grade <br /> Fk L.�_�i; :'Jr�3�7�:� "'O�t ZS �J� GROUTINGINFORMATION <br /> Well grouted? CS Yes ❑ No <br /> .. � _ _,. .. .- ,.A,; 4:`a��. ��7 y�7 Grout Material ❑ Neat cement IXBentonite <br /> ��� {� to >� ft. ❑ yds. ❑ bags <br /> from <br /> from to ft. ❑ yds. ❑ bags <br /> � - •-���- � ' d'� ' � � from to ft. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION 1 t1 7 1:I;-.=' <br /> _``�i feet �i}`+�l.;"_ direction . �,� rype - <br /> Well disinfected upon completion9 .O Yes ❑ No '` �" <br /> PUMP / <br /> ❑ Not installed Date installed _____71 7 T.��!w' <br /> Manufacturer's name ,�%`s ill;�L:s L' <br /> Model number HP � i -'. Volts ��`� <br /> Length of drop pipe ;,Q� ft. Capacity 1� g.p.m. <br /> Pressure Tank Capacity_�o u i <br /> Type: �.� Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS - <br /> Does property have any not in use and not sealed well(s)? ❑ Yes C��No <br /> WELL CONTRACTOR CERTIFICATION -- <br /> This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> The information contained in this report is true to the best of my knowledge. <br /> Use a second sheet,il needed ....1'i€��.. ..'�r v i�`.: i.� . t- i� �. .. . <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee Business Name Lic.or Reg.No. <br /> f �! <br /> � 19�6 _ : <br /> ti�A = r H�` ����' ���'`_ <br /> N � ��i,� .�.�;-'� a_ - �► �. <br /> ��Authorized Representative Signature --j Date <br /> rta4r� _ . -. _. ._:+�:... �Y 7J.?_7/9:� <br /> Name of Driller Date <br /> LOCAL COPY 5 5 9 6 4 4 HE-01205-04(Rev.S/92) <br />